“Can eye movement problems be related to torticollis?”

Ocular Torticollis

Torticollis can be caused by several things. Delays or problems in the integral development of muscle tone, the vestibular system and propreioception can all be causes.  Eye alignment, nystagmus and acuity problems can also affect head position.  When vision is the primary cause for torticollis, it is referred to as ocular torticollis.  One study found 20% of torticollis related to ocular problems. (1)

Eye alignment

Head tilts and head turns are common signs of eye alignment problems. Deviations between eyes in the horizontal plane (hyper- or hypo- tropia) can cause head tilts in the brains attempt to see a single, fused image. Head turns (rotation) to right or left can be caused by strabismus (eso- or exo- tropia). Again, the brain turns the head in attempt to not see double. Other more complex movement patterns can also cause head position and posture problems.

Nystagmus

Nystagmus is an involuntary movement of the eyes. This is generally associated with a neurological problem. They can be congenital or acquired. Many times, patients with a nystagmus will turn their head to find the point at which the nystagmus stops. This point, called the “null point” allows for improved vision for the patient.

Acuity problems

Astigmatism, a condition in which the eyeball is not perfecting round but more football shaped, can also cause visual acuity problems that might facilitate a head tilt in order to improve vision.

Eye Exam

Every child should have their first eye exam at 6 months (per AOA recommendations). A through eye exam that includes a binocular vision exam would find eye alignment problems most likely to cause ocular torticollis.  If treating a patient with torticollis of unknown cause, a binocular vision exam could be helpful in identify the problem. Frequently, prisms and lens can be prescribed that can help reduce the torticollis.

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Motion sickness and the eyes

Motion Sickness

As part of my vision rehab evaluation with patient I always ask about motion sensitivity (or car sickness). The answer can give cues to the functioning of the ambient (magnocellular)visual system.

What is motion sickness?

The semicircular canals within the ears (vestibular system) tell the body that it is motion. The magnocellular visual pathway also “confirms” this motion as movement is observed. But when the system is less aware of magnocellular output (such when one is reading or playing a game in the car) then the vestibular and the magnocellular system get different information. When this happens nausea and rest follow.

The magnocellular system

The magnocellular system is responsible for visual input that affects gait, posture and balance. It also helps us track during reading as it gives the brain the ability to see the line peripherally as the eyes focus on the words being read. There was some discussion that magnocellular problems were associated with dyslexia as well.

Treating the Magnocellular system

To improve magnocellular input, we do activities on a balance board while performing visual scanning tasks that emphasize keeping the head still and maintaining balance as targets are toughed. I will have patient do this while wearing glasses with binasal occlusion or base up or down prism depending on posture. This can also be helpful with idiopathic toe walking.

More recently, motion coherence tests have been developed which help to quantify magnocellular function. In these computer based tests, dot move randomly and the patient must decide which direction most of the dots are moving. Devices like the Neuro-tracker also work on magnocellular function.

Using the system as tool

The magnocellular system can be a powerful tool in improving posture and balance. The altered visual input quickly re-aligns posture without cueing and makes use of the brain natural ability.

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The Brock String

The Brock String

The humble Brock consists of a length of string (from 3 to 10 ft) with a series of beads (from 3 to 5 beads) placed at various intervals. This simple instrument is powerful tools in teaching binocular vision skills.  While the configurations vary, it is elegantly simple and effective in teaching the brain how to make the eyes convergence.

How the use a Brock string

The 3 ft string is generally sufficient unless working with an athlete then a longer string my be needed. Four or five beads make for enough targets to be useful.

  1. With the beads evenly spaced (closest bead at about 2cm, furthest about 40 cm), have the patient hold one end of brock string to their nose.
  2. The therapist holds the string tight and angled slightly downward.
  3. Have the patient fixate on one of the further beads to begin. The patient should see one bead (indicating focus to a single point) and two strings meeting at the front of the bead (indicating both eyes are working together. It should look like the picture below.
  4.  Have the patient alternate from bead to bead, working closer and back to exercise the convergence muscles. Look for difficulty with maintaining the fixation as the muscle fatigue.

Brock-String-4-300x65Here is the video about the Brock String.

Why does this work?

The brock string takes advantage of “physiologic diplopia”. The eyes can only focus clearly on single point with all other things within the viewing area seen as double. This is a normal way for our eyes to work. The brock string uses this physiologic diplopia as a cue to the let brain know the eyes are working together correctly.

Remember, before the brock string, check for full extra ocular movements and exercise the eyes separately.

Brock strings are easy to make and make a great home program addition.

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The Binocular Vision Exam

The Child’s Special Visual System

Children’s eyes are amazing. They bring the world to an eager child and facilitate development of many skills.  The visual world influences posture and gait, fine motor development, letter recognition on to reading skills and many other areas.  The importance of good vision cannot be over stated.

The Pediatric vision exam

The vision exam for a child should include assessments not generally not performed on adults. Check out this post first to understand how we see up close. 

  • Cyclopelgic Dilation and Refraction- This allows for the doctor to completely exam the retina of a child for optic nerve problems and other congenital problems that child may have. The cyclopelgic dilation also relaxes the ciliary muscles which control accommodation (focusing of the lens within the eye). This allows the doctor to exam the true refractive error of the eye which can frequently be corrected by the accommodation of the lens.  This should be considered mandatory once a year.
  • Near Point of Convergence – This brief assessment allows for the doctor to assess how how well the eyes are working together when seeing up close.
  • Measured cover test- A cover test reveals the amount of effort needed for the eyes to maintain their position. It also shows subtle eye movement problems like strabismus.
  • Retinoscopy – in this assessment, the doctor can get an objective measurement of refractive error. This eliminates communication problems some children may have and makes for the most accurate solution for a child;s visual acuity.

Better or Worse

General optometrists and opthamologists may or may not perform these tests.  Without them, an important part of the assessment of a child’s vision has been left out. Eye movements can cause delays in gross and fine motor development and decreased reading performance and difficulty in sports, like hitting or catching a baseball.

Look for doctors that advertise being pediatric or binocular vision specialist. Look for doctors that members of the College of Visual Development or the Neuro – Optometric Vision Association.  These are doctors that specialized in the assessment of binocular vision skills.

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ADHD and Eye Movements

ADHD and Eye Movements

There is much research concerning the link between eye movements and ADHD. Researchers consistently find specific eye movement behaviors associated with ADHD. But how does this research help in the clinic?

ADHD and Saccades

Much of the ADHD/Eye movement research has focused on the quick, exploratory eye movements called saccades. Children diagnosed with ADHD show saccade accuracy consistent with their peers. They are able to quickly and accurately look to a new target in the environment. When instructed not to look a target (anti-saccades), children with ADHD have a more difficult time NOT looking at the stimulus (1). Reading is a series of quick fixations and saccades that affects reading speed. These saccades improves reading fluency in children(2) . Children with ADHD also show reduced tracking ability which further affects reading fluency (3)  (4).

Near Vision and ADHD

Convergence Insufficiency, an eye movement disorder affecting one’s ability to maintain clear near vision, is found at three times the rate in ADHD children compared to those not diagnosed with ADHD(5).  A study also shows that children with symptomatic convergence insufficiency score higher (more negative behaviors) on an academic behavior scale then those children diagnosed with ADHD (7). So convergence problems can be associated with ADHD-like behavior problems.

ADHD and Optometry

Optometry is aware of the link between eye movements, behavior and academic performance. ADHD symptoms can mimic the behavioral signs of eye movement problems, even when a child is unable to vocalize the vision problems he is has having. Treatment of convergence problems is also known to reduce the symptoms of ADHD reported by parents (6). Treating saccade and tracking problems also helps to improve reading fluency and improve academic performance.

Only a complete evaluation by an optometrist that specializes in eye movement problems can help identify these problems that could be limiting performance in a child with ADHD. Treatment of these problems with in-office vision therapy can help improve a child’s academic performance.

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Dyslexia and Vision Rehabilitation

Dyslexia and Vision Therapy

Dyslexia is word frequently tossed about when children have problems reading or learning. Commons complaints that lead to the use of the word include letter reversals, poor reading comprehension and decreased reading fluency. These symptoms are also recognized as possible vision related problems cause by poor eye movement accuracy.

Is dyslexia a vision problem or a language problem?

Attempting to define dyslexia can be confusing. The origin of the word is vague: “dys” meaning difficulty with and “lexia”  meaning reading lends itself to broad interpretation.  The best definition for dyslexia, from the International Dyslexia Association says:

“Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.”

The research shows that the root cause of dyslexia is phonological processing, or how the brain processes sounds in language. Additionally, the prevalence of dyslexia is estimated to be between 5-20% of the population, according to the National Institute of Health: http://www.ninds.nih.gov/disorders/dyslexia/dyslexia.htm. *

Reading is a complex process involving language, speech, memory and other processes, but all of these processes assume that the collection of the information to be processed is accurate, ie that the eyes work correctly and move accurately. We do know that poor eye movements lead to poor processing skills because the data to be processed was not collected accurately.

Does vision therapy treat dyslexia?

This is also a very interesting question. In our vision rehab practice, we frequently get children referred to us that have common symptoms of dyslexia and visual processing difficulties like reversals and poor reading skills. Following the interventions, the children have reduced symptoms and most have improved reading fluency.

Some of patients do continue to have problems in reading although they show improved eye movements. At this point, we may further assess the patient using a dyslexia screening tool that can identify specific errors related to the processing parts of reading such as the decoding and encoding of words. When results indicate, we refer those children to specialists like our friends at Read-Write Learning Center at  that specialize in the treatment of dyslexia.

 

Does vision therapy treat dyslexia????

NO. Vision therapy cannot treat dyslexia. But it does improve the accuracy of eye movements eliminating many of the symptoms generally associated with dyslexia. With these eye movement problems gone, an accurate assessment of the visual processing skills and reading fluency is now possible, allowing for an accurate diagnosis of a visual processing or other reading and learning problems.

Here is a video case study describing the process.


*Special thanks to Hunter Oswalt, Director of the Read-Write Learning Center for her input on editing this post.

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Visual Processing Disorder

Visual Processing Disorder

Visual Processing disorder is broad term used to describe children that have difficulty with visual tasks. They may have problems with puzzles, mazes, handwriting or reading. The child may be clumsy and have difficulty remembering things like where toys are located. Visual processing problems can be different in each child. Here is a symptom checklist that might help.

Sensory Processing Disorders

Visual processing disorders are part of a larger group of disorders called “sensory processing disorders“. Sensory processing disorders can be linked to any sense (touch or hearing, vision, taste or smell) and are characterized by the brain magnifying or muting sensory information. This magnification or muting of the sensation can appear a child that does not like loud noises, or constantly likes to touch rough surfaces. They may be picky eaters because some foods “feel funny” in their mouths or they only wear their favorite super soft shirt.

These sensory difficulties can cause problems with fine and gross motor development as well as academic performance and cause behavioral issues as well.

Causes of Sensory Processing Disorder

Research continues to identify causes of these disorders but no real conclusions have been found. There are differences in brain structure noted in these children and environmental toxins have been linked to these disorders.

Treating Visual Processing Disorder

Children diagnosed with visual processing disorder should first have complete eye exam including a binocular vision exam. Children with visual processing disorders and other sensory disorders are frequently found to have eye movement and near vision focusing problems that only a binocular vision assessment can uncover. Treatment for the eye movement and near vision focusing problems can frequently reduce the symptoms associated with visual processing disorders.

Following resolution of the eye movement problems, we can ONLY THEN begin successful treatment of visual motor integration and visual perception problems.

Neurological Events and Visual Processing disorders

Recently, I have had several children referred to me recently with “visual processing problems” that also have histories of seizure disorder and concussion. These children also had significant binocular vision problems. Once their binocular vision disorder was correctly diagnosed (both had CI, accommodative dysfunction and saccade dysfunction) and treated, we then able improve visual processing for both of these children.

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